Tex. Ins. Code Section 1698.052
Additional Rules and Guidance Related to Individual Health Plan Rates


In this section, “qualified health plan” has the meaning assigned by Section 1301(a), Patient Protection and Affordable Care Act (42 U.S.C. Section 18021).


The commissioner shall adopt rules and provide guidance regarding additional requirements related to individual health benefit plans, including qualified health plans, to address the following factors:


whether the plan issuer has complied with all requirements for pooling risk and participating in risk adjustment programs in effect under state or federal law;


the covered benefits or health benefit plan design or, for a rate change, any changes to the benefits or design;


the allowable variations for case characteristics, risk classifications, and participation in programs promoting wellness; and


any other factor listed in 45 C.F.R. Section 154.301(a)(4) to the extent applicable.


In making a determination under this section regarding a proposed rate for a qualified health plan, the commissioner shall consider, in addition to the factors under Subsection (b), the following factors:


the purchasing power of consumers who are eligible for a premium subsidy under the Patient Protection and Affordable Care Act (Pub. L. No. 111-148);


if the plan is in the silver level, as described by 42 U.S.C. Section 18022(d), whether the rate is appropriate for the plan in relation to the rates charged for qualified health plans offering different levels of coverage, taking into account any funding or lack of funding for cost-sharing reductions and the covered benefits for each level of coverage; and


whether the plan issuer utilized the induced demand factors developed by the Centers for Medicare and Medicaid Services for the risk adjustment program established under 42 U.S.C. Section 18063 for the level of coverage offered by the plan or any state-specific induced demand factors established by department regulations.


The commissioner may consider the following factors:


if the commissioner determines appropriate for comparison purposes, medical claims trends reported by plan issuers in this state or in a region of this country or the country as a whole; and


inflation indexes.
Added by Acts 2021, 87th Leg., R.S., Ch. 877 (S.B. 1296), Sec. 1, eff. September 1, 2021.

Source: Section 1698.052 — Additional Rules and Guidance Related to Individual Health Plan Rates, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­1698.­htm#1698.­052 (accessed Dec. 2, 2023).

Dec. 2, 2023

§ 1698.052’s source at texas​.gov